Bond Eye Associates - LASIK Quiz

1

What is your current age?* This field is required.

Under 18

18 - 39

40 - 59

60+

2

Are you in good general health?* This field is required.

YESNO

3

Do you currently wear...* This field is required.

Glasses

Contacts

Glasses & Contacts

Nothing

4

Without corrective lenses, do you have...* This field is required.

Trouble seeing far away

Trouble seeing up close or with reading

Overall blurry vision both distance and near

5

Are you being treated for severe dry eyes?* This field is required.

YESNO

6

Have you ever had eye surgery?* This field is required.

YESNO

7

Have you ever been diagnosed with astigmatism?* This field is required.

Yes

No

I don't know

8

Have you ever been diagnosed with cataracts?* This field is required.

YESNO

9

What is your name?* This field is required.

First Name

Last Name

10

What is your phone number?* This field is required.

Area Code

Phone Number

11

What is your email address?* This field is required.By including your email address, you are providing consent for Bond Eye Associates to send you marketing emails in the future.

example@example.com